A parent emailed me recently: “Dr. D, Michael experiences dryness upon removing his ortho-k contact lenses. He says it bothers him at school. He did not have this problem beforehand. Please advise!” The benefit of orthokeratology (ortho-k) for patients who have dry eye syndrome has been cited, including in this very column (Lipson, 2019). But, ortho-k has been associated with symptoms of dryness (Wang et al, 2019). So, what can we do when ortho-k is the problem?

Top Etiologies

In my experience, here are the top etiologies when dry eyes are associated with ortho-k:

1. Epiblepharon This is a horizontal fold of redundant skin causing the eyelashes to be directed vertically or to invert to a small degree. Epiblepharon is common among Asian patients; it is said to be present in about 50% of Asian children less than a year old (Weber et al, 2020). This condition is usually asymptomatic and, if not noted during the fitting process, may become relevant during contact lens wear.
   Most of my patients wearing ortho-k lenses are of Asian descent, and I’m guilty of overlooking eyelid anatomy in relation to the cornea during some of my consultations. Children are often hyper-aware of how their eyes feel during the day. In rare cases when we are unable to resolve the issue with epilation and lubrication, we’ve sent children out for surgical reconstruction. The key to successfully fitting children with ortho-k when epiblepharon is present is educating the parents of its existence during the consultation as well as informing them of the possibility of symptoms arising once the child begins wearing the contact lenses.
2. Meibomian Gland Dysfunction (MGD) It’s unclear whether the increased complaint of dry eyes among our pediatric patients is due to an increased use of screens, but I get this complaint more and more, even among non-contact lens wearers. Although rare, MGD can be present in children (Tichenor et al, 2019). I now perform a thorough examination of a child’s eyelids during his or her initial contact lens evaluation. I’ll also inquire as to whether a child is susceptible to styes, often eliciting a puzzled look from parents who respond affirmatively. When I note MGD during a biomicroscopic exam, I educate parents about it prior to fitting the child with lenses.
3. Incomplete Blinking This can easily be missed during an evaluation and will come back to haunt us once the child starts wearing lenses. Hence, it is prudent to do a careful baseline biomicroscopic evaluation. When I suspect incomplete blinking, I also ask whether the child sleeps with his or her eyes open.
4. Lens Fit Issue Ortho-k works by using hydraulic forces under a contact lens. When a lens is too steep or flat, it can cause superficial punctate staining (SPK). When SPK is noted, we carefully reevaluate the fit and address issues contributing to its formation, which often alleviates symptoms of dry eye and wards off a potential adverse event.
5. Chemical Toxicity Most GP solutions and lubricating drops contain preservatives that can be toxic to the corneal epithelium, especially because the solution remains under the lens overnight. In cases in which this occurs, we switch children to a hydrogen peroxide system and use preservative-free eye drops.

How It Worked Out

In Michael’s case, it turned out to be severe MGD. I had a lot of explaining to do, because I had not noted this during my evaluation. We treated him with conventional warm compresses followed by aggressive eyelid massage, performed nightly. With time, his MGD resolved, as did his symptoms of dry eye.

It’s normal for our attention as clinicians to focus on the intricacies of fitting an ortho-k contact lens. But I’ve learned to slow down during my evaluation, allotting more than an hour to the exam and educating parents on my findings and recommendations…making my consultation more cut-and-dry. CLS

For references, please visit www.clspectrum.com/references and click on document #296.